Exercise Training and Depression in ESRD: A Review Georgia I. Mitrou,* 1 Stefania S. Grigoriou,*† 1 Evi Konstantopoulou,* Paraskevi Theofilou,†‡ Christoforos D. Giannaki,§ Ioannis Stefanidis,¶ Christina Karatzaferi,*† and Giorgos K. Sakkas*†¶ *Department of PE and Sport Science, University of Thessaly, Trikala, Greece, †Department of Kinesiology, Centre for Research and Technology Hellas, Greece, ‡Department of Psychology, Panteion University, Athens, Greece, §Department of Life & Health Sciences, University of Nicosia, Cyprus, and ¶School of Health Science, Department of Medicine, University of Thessaly, Larissa, Greece ABSTRACT Depression, a mental disorder with a high personal, socie- tal, and economic impact, affects at least 20–30% of patients receiving hemodialysis therapy. It is associated with a high mortality rate, low adherence to medication, and a low perceived quality of life. Exercise training is a promising nonpharmacological intervention that can be safely applied to these patients. Beyond the well-publi- cized physiological benefits of exercise training, a number of studies have focused on the effects of exercise training on mental factors and quality of life parameters including its less appreciated effects on depression symptoms. This evidence-based review article reviews and discusses the effects of exercise training on depression in end-stage renal disease patients. Patients receiving hemodialysis (HD) therapy have a low quality of life (QoL), often accompanied by significant emotional distress characterized by symptoms of depression and anxiety (1). Depression is the most common mental disorder in HD patients (2) and is second only to hypertension in frequency as a comorbid diagnosis (3,4). In the last decade, nephrologists have begun to look more systemati- cally for signs of depression as its recognition as an important factor influencing a patient’s overall health status and survival (5). It may also be one of the major contributors to the low medication adher- ence observed in dialysis patients, which by itself is associated with increased mortality risk (5). There is evidence that physical activity and exer- cise training improve the general health of patients with end-stage renal disease (ESRD) reducing the burden of common associated comorbidities (6–8) including hypertension, heart diseases, musculoskel- etal problems, and diabetes mellitus (9). There is also strong evidence suggesting that systematic exer- cise training and high physical activity levels are effective and safe nonpharmacological treatments, which improve both mental and physiological aspects of health with direct effects on patients’ QoL and mortality (10). Most studies of this subject have assessed depres- sion score as a “side parameter” or as an aspect of the patients’ QoL score (11). In addition, there are investigations assessing the effectiveness of exercise training compared with other nonpharmacological approaches for the improvement of the mental health (MH) of HD patients or more specifically, depression. The aim of this review is to describe and cover in critical fashion the data that do exist on the effect of exercise training programs on depressive symp- toms encountered in HD patients and assess whether exercise is a useful nonpharmacological tool for improving patients’ MH. Prevalence and Symptoms of Depression in HD Patients Depression affects approximately 20–30% of ESRD patients (12–15); some studies have reported even higher percentages (16). Many factors contrib- ute to the high prevalence of this disorder in the HD population including an amalgam of mental, physical, and social factors that frequently coexist and result in high levels of emotional distress. Depression is also linked to the dialysis treatment itself, which requires from patients long periods attached to the dialysis machine, a fact that clearly Address correspondence to: Giorgos K. Sakkas PhD, Department of Kinesiology, Institute of Research and Technology Thessaly, Centre for Research and Technol- ogy Hellas (CERTH), Karies, Trikala, Thessaly, GR42100, Greece, Tel.: +30-2431-500-911. Fax: +30-2413-501667, or e-mail: gsakkas@med.uth.gr. 1 Equal first authors. Seminars in Dialysis—Vol 26, No 5 (September–October) 2013 pp. 604–613 DOI: 10.1111/sdi.12112 © 2013 Wiley Periodicals, Inc. 604